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Mental injury assessment

A psychiatrist or psychologist completes this assessment when they receive a referral from ACC

to assess an ACC client for a mental injury arising from physical injuries or from experiencing a work-related traumatic event.

The guidelines at the end of this form provide detailed information on how to complete in each section. Please read these to familiarise yourself with the specific requirements of this assessment report.

Please forward the completed assessment to the ACC staff member making the referral.

|1. Provider details | |

|ACC provider number:       |Date of report:       |

|Treatment provider name:       |

|Treatment provider address:       |

|Treatment provider type: | Psychiatrist | Psychologist |Other (please specify):       |

|Date(s) of consultation:       |Duration(s) of consultation:       |

| |

|2. Client DETAILS | |

|Client’s full name: - - - |Date of birth: - |

|Client’s address: - , - , - , - , - , - |ACC45 number: - |

| |

|3. ACC Staff Details | |

|ACC Client Service staff member: |ACC office: |

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|4. Introduction | |

|A. Sources of information: |

|      |

|B. Confidentiality and competence: |

|      |

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|5. background information | |

|A. Client details: |

|      |

|B. Summary of relevant background history: |

|      |

|C. Presenting problems: |

|      |

|D. Past psychiatric/psychological history including treatment history for presenting problem: |

|      |

|If the client has received any treatment from another health provider for this condition, please provide a contact name and address of the provider(s). |

|Contact name:       |

|Contact address:       |

|E. Relevant past medical history: |

|      |

|F. Current medications and dosages: |

|      |

|G. Alcohol and drug history: |

|      |

|H. Family history: |

|      |

|I. Employment-related issues: |

|      |

|J. Personal history: |

|      |

|K. Summary of previous tests or assessments: |

|      |

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|6. Diagnosis | |

|A. Personality assessment: |

|      |

|B. Mental State Examination (MSE): |

|      |

|C. Formulation/summary: |

|      |

|D. Diagnosis: |

|      |

|E. Risk assessment: |

|      |

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|7. Opinion | |

| A. Relationship between the physical injury and/or event and the mental condition: |

|      |

|B. Relationship between other life events and the mental condition: |

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|C. Post-Traumatic Stress Disorder (PTSD). |

|      |

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|8. Prognosis | |

|What is the prognosis for this client’s mental condition? |

|      |

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|9. Further Information | |

|Other relevant information: |

|      |

The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code 1994.

Guidelines for completing mental injury assessments

These guidelines are to help you assess ACC clients who have lodged a claim for a mental injury caused by a physical injury or work-related mental injury. Section A discusses key terms, and Section B is the guidelines for completing the ACC4247 mental injury assessment.

Part A – General key terms for assessment of work-related mental injury and mental injury caused by physical injury

Guidelines

These guidelines have been informed by clinicians in the mental health field who were brought together by ACC to provide clinical advice on the cover process and these guidelines.

Cover

Deciding cover for mental injury involves establishing that the physical injury or work-related traumatic event has materially contributed to the development of a clinically significant behavioural, cognitive or psychological dysfunction, ie a ‘mental injury’ as defined in the Accident Compensation Act 2001.

Deciding cover for work-related mental injury requires establishing that the event meets the criteria for a ‘traumatic event’ that is directly experienced, seen or heard by the client. For these claims, the client does not need to have a physical injury.

Traumatic event

To be considered a traumatic event, the event must meet all of the criteria.

The event:

• was a single, sudden event or the direct outcome of a sudden event

• could reasonably be expected to cause mental injury in people generally because it:

• is outside the range of normal experience

• is capable of provoking extreme distress in most people

• involves a real threat of significant harm to self or others

• would induce feelings of horror, alarm and shock in most people

• occurred in the course of the client’s work

• occurred when the person was in close proximity to the event itself and experienced it directly (ie not seeing it on TV or hearing about it on the radio or from others).

Clinically significant mental injury

To be considered a clinically significant mental injury, ACC requires a diagnosis based on a diagnostic framework that supports the concept of clinical significance, ie DSM IV or DSM-5, Psychodynamic Diagnostic Manual (PDM) or other classification system. The mental injury assessment must differentiate between a normal distress response and a persisting response, which is associated with dysfunction or disability. We recommend that you use the World Health Organisation Disability Assessment Schedule (WHODAS 2.0) to assess disability as DSM-5 is no longer multidimensional and it no longer includes the Global Assessment of Functioning.

The following items should be included in the assessment:

• Collateral information about the signs and symptoms, and resulting impairment.

Collateral information can be in the form of past medical records or accounts from family, friends, educational providers or employers pre-and post-injury. This information might help to provide a more accurate and fuller picture of pre-and post-injury presentation. It might also help to determine the clinical significance of any impairment resulting from injury in the client’s social, occupational and other relevant environment.

• Consideration of symptom exaggeration and how it effects the diagnosis

Symptom exaggeration is occasionally an important feature of a clinical presentation. In the cover process, an exaggeration of a client’s symptoms may undermine the ability of the clinician to draw conclusions about the mental health condition or the event. For this reason, and to avoid singling out any particular individual, evaluation for symptom exaggeration should be conducted as a routine part of the assessment process. ACC may seek further opinion if required.

• Use of standardised instruments to provide supportive information for the clinical formulation

The use of psychometric instruments can help determine the symptoms the client is experiencing and can assist in focusing the interview. Consider both, qualitative and quantitative data without exclusive reliance on one or the other. Using psychometric instruments that help determine the consistency of the reported symptoms can inform an objective evaluation. Where any significant inconsistency arises, consider the options for investigating this further.

• Diagnosis of mental injury and its relationship to the physical injury or event

In the mental injury assessment, you should demonstrate that the onset or development of symptoms was caused by the physical injury or work-related event. Provide a careful inquiry of pre-injury symptoms.

The physical injury or event must have materially contributed to the condition diagnosed as clinically significant. It is important to distinguish whether the physical injury or work-related event caused the mental injury, rather than it being a trigger or the ‘final straw’ in a succession of stressful events.

Examining GP notes, occupational health notes or other notes from relevant health professionals will help provide supporting discussion and documentation. These will be particularly important in assessing claims where the physical injury or event occurred some time ago.

Key terms

Below are the relevant legislative terms and phrases used by ACC to determine cover for this type of claim.

|Term |Definition and explanation |

|Mental injury |A clinically significant behavioural, cognitive, or psychological dysfunction (defined in section 27 |

| |of the Accident Compensation Act 2001). ACC considers that a psychological dysfunction is considered |

| |clinically significant if it meets the diagnostic criteria specified in currently available diagnostic|

| |tools. |

| |All diagnostic formulations must be made with reference to the diagnostic tool used. |

|Materially contributed |To satisfy s 26(1)(c) of the Act, the physical injury or work-related event must be a cause of the |

| |mental injury in some genuine or meaningful way, rather than just in a trivial or minor way. |

|Event |An event means: |

| |an event that is sudden; or |

| |a direct outcome of a sudden event; and |

| |includes a series of events that: |

| |arise from the same cause or circumstance; and |

| |together comprise a single incident or occasion; but |

| |does not include a gradual process. |

|Experience directly (including involved) |To be directly involved in an event, that happens to a person directly. |

|See or hear directly (including witnesses) |Experiencing, seeing or hearing an event first hand, and not through a secondary source. Secondary |

| |sources include television, closed circuit television, telephone, seeing pictures, reading or hearing |

| |about it in news media, or from another person. |

|Close physical proximity to the event at the time |To be physically present at the place where the event takes place or close enough to be able to |

|the event occurs |experience, see or hear, and be affected by the event. |

|A direct outcome of a sudden event |The event can be the direct outcome (aftermath) of the sudden work-related event, eg what happens at |

| |the scene of the event or immediately after being moved away from the scene. For example, emergency |

| |workers who attend the scene after the event or hospital staff treating injured people. |

Part B – Guidelines for completing the ACC4247 Mental Injury Assessment

Sections 1, 2, and 3:

Please complete all sections.

Section 4: Introduction

A. Sources of information

Please list and number all sources of information used in undertaking the assessment. These should identify the nature of the information, eg document, interview etc, the origin or author of the information, and the date of the information. If undated, please note.

Information that is known to be available, yet was not available to the assessor, should also be acknowledged here.

B. Confidentiality and competence

Please record the client’s consent and competence to participate in the assessment, including their ability to understand the purpose of the assessment, and their capacity to provide valid information.

Section 5: Background information

A. Client details

Please identify the client’s demographic and general social circumstances at the time of assessment. If other people accompanied the client, note their name and relationship to the client. Some authors may include this information in some other section of their report.

B. Summary of relevant background history

Fully describe the accident or event resulting in this claim as presented to you by the client. This section may include a summary of historical issues, which serves to set the platform for the assessment. This must include an account of the physical injury, work-related incident or event that resulted in the claim, so that the context can be set for the current assessment.

C. Presenting problems

It’s important to identify complaints made by the client and to give a comprehensive account of any clinical signs or symptoms described. It’s also important to record any resulting impairment or disability, and the extent to which each impedes full rehabilitation for the client. The World Health Organisation Disability Assessment Schedule (WHODAS 2.0) would be an appropriate measure of disability which has been recommended to accompany DSM-5 diagnoses.

It can be helpful to comment on any other assessments that have been previously completed and identify where, if at all, the client’s account of physical injury or events differs. Please reference information outlined in this section clearly and accurately.

D. Past psychiatric/psychological history including treatment history for presenting problems

Please summarise any past psychological and/or psychiatric history. Give a clear account of the times treatment was received, what the treatment was, what were its effects, and what, if any, were the identified problems.

E. Past relevant medical history

Include any past medical history if it is relevant to this referral.

F. Current medications and dosages

List all current medications and dosages and any relevant past medication.

G. Alcohol and drug history

Please record a full alcohol and drug history if relevant. Include the nature, frequency, pattern of use or behaviour over time and amounts of any alcohol and substances that might be used. Record whether the client describes any symptoms or signs of abuse or dependence, what problems their alcohol or drug use may have caused them, whether they have accessed previous treatment or rehabilitation programmes, and whether these were successful. It’s particularly important to record the current pattern of use, and what difficulties this might be causing the client in areas that might be important for occupational rehabilitation. If a diagnosis of any alcohol or drug related problem is made, please include the raw data to support your diagnosis.

H. Family history

A summary of family relationships and functioning is useful. Record any family history of mental health, alcohol or drug problems.

I. Employment-related issues

Record any relevant issues the client has in their workplace that could influence their presentation.

J. Personal history including other significant life events or incidents separate from the incident behind this claim

A general summary of the client’s personal history is important. If any mental health disorders are identified, then a more comprehensive account of the personal history is appropriate. Please take care to only record personal information that is clinically relevant. Possible information includes childhood and early development, schooling, friendships, intimate relationships, occupational history, adult relationships, children, pastimes and activities.

Include details of any occupational functioning over time.

K. Summary of previous tests or assessments

You may find it helpful to identify other tests or assessments that may have been undertaken previously, particularly if there were findings relevant to the current assessment. This is also an opportunity to identify other tests or assessments that may be helpful in further clarifying aspects of the client’s presentation.

Section 6: Diagnosis

A. Personality assessment

Clinical and/or standardised testing may be undertaken to identify relevant aspects of personality function. We ask you obtain sufficient supporting evidence before you complete the personality function assessment.

B. Mental state examination

A full mental state examination (MSE) should be undertaken, and relevant findings recorded in each report. This should include all areas of an MSE using an accepted format with a comprehensive account of any relevant abnormal phenomena. It should also include a comment on suicide risk, any thoughts of harm towards others, cognitive function, and assessment of insight and judgement.

C. Formulation/summary

Please provide a clear formulation explaining how the client has developed any presenting difficulties. The formulation requires a narrative summary of all of the factors, both positive and negative, specific to an individual client that clearly explains why and how the client has developed the difficulties they are currently presenting with, and why these difficulties have persisted. It should also include discussion of identified barriers to psychosocial recovery and occupational rehabilitation. The formulation does not need to be long but should succinctly encompass aspects of the individuality of the client. Please do not simply copy and paste previous sections, but rather summarise key information that contributed to the client’s current presentation.

D. Diagnosis

Please outline any formal psychiatric or psychological diagnoses that you think are appropriate and reference them clearly to the classification system used. Consider the following questions:

• In your opinion, does the client have a clinically significant mental condition? If so, what factors indicate this?

• What is the diagnosis? Please define precisely and outline the classification system used.

• If in your opinion your diagnosis differs from the mental condition being applied for, please give reasons for the difference.

E. Risk assessment

Where appropriate, please undertake a risk assessment and reference this to an accepted method of conducting such assessment, ie HRC 20, static and dynamic risk. This assessment should formulate risk and identify any particular situations in which the client may present issues of risk, including ways in which these risks can best be monitored and mitigated.

Section 7: Opinion

A. Relationship between the physical injury or event and the mental condition

Please answer the question “Has the physical injury or work-related event materially contributed to the diagnosed mental condition(s)”? If there is more than one diagnosis, consider each diagnosis separately and provide a rationale for your conclusion(s). Consider the guidelines provided.

For definitions of ‘event’ and ‘mental condition’ see Section A.

B. Relationship between other life events and the mental condition

Please outline what other issues, life events, or incidents, separate from the claimed injury or events of this incident, if any, may have contributed to the client’s current mental condition.

Please indicate what effect these are having on the client’s mental state.

C. Post-Traumatic Stress Disorder (PTSD)

If the diagnosis is Post-Traumatic Stress Disorder, describe:

• how the client meets the different criteria associated with this disorder

• the traumatic features of the incident behind this claim, including whether the critical features were directly experienced by the client and the client’s response to these features

• the ways in which the client persistently re-experiences the traumatic events

• which indicators are present that the client persistently avoids stimuli associated with the trauma and has numbed general responsiveness not present before the trauma

• which persistent symptoms of increased arousal not present before the trauma the client suffers

• the duration of the disturbance

• the manner in which the disturbance has materially contributed to the clinically significant distress or impairment in functioning.

In terms of the DSM-IV diagnostic criteria for PTSD, an event is considered traumatic if it involved, amongst other things, death or serious injury, or threat of serious injury. ACC generally expects a physical injury to be serious or accompanied by threat of serious injury if it is a material cause of PTSD.

If the claim is for PTSD arising from a physical injury, please answer the following:

• in your opinion, are the physical injuries the client suffered as a result of the events serious? Please specify which injuries you consider serious and why

• in your opinion, did the client face a threat of serious injury during those events?

• please explain why the physical injuries have materially contributed to the PTSD if

- you do not consider these injuries serious; and

- the events did not involve a threat of serious injury

Section 8: Prognosis

What is the prognosis for this client’s mental condition?

If applicable, please indicate your prognosis for this client’s mental injury and the severity of the client’s condition.

Section 9: Further Information

Other relevant information

Please provide any other relevant information that may help ACC to determine whether the client has suffered a mental injury as a result of a physical injury or experiencing, seeing, or hearing a traumatic event at work.

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ACC4247

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